Address
Form of workPeople are the most important asset of Imperial, for this reason the difference and plurality of people, equality of opportunities, non-discrimination and inclusion in the workplace are priority and strategic factors in the Organization. Imperial maintains a strong will to promote Diversity, Equity, and Inclusion, through inclusive leadership as a lever change and business sustainability.
Imperial Health Plan of California, Inc. is approved by California Department of Managed Health Care to offer full-service Medicare Advantage coverage, including a Medicare Advantage Prescription Drug plan, and a Chronic Condition Special needs plan over numerous counties in California. Through its affiliate, Imperial Insurance Companies, Imperial also offers Medicare Advantage plans in Texas, New Mexico, Utah, and Arizona.
Our Mission: To deliver valuable care so that members are healthy in body, mind, and spirit to achieve their inherent potential.
Our Vision: To deliver value based care that is clinically effective, sustainable, and achieves exceptional outcome.
JOB DUTIES:
The UM Manager, Clinical Services is responsible for providing operational leadership to the day to day function of the UM/Prior Authorization Team. The UM Manager, Clinical Services will ensure that the team complies with Federal, State, Health Plan and NCQA requirements
ESSENTIAL JOB FUNCTIONS:
1. Collaborating with clinical and non-clinical personnel providing timely care which complies with generally accepted standards of clinical practice.
2. Assigns work schedules, delegates reviews, provides direction on review priorities, meets the demands of internal and external partners, and ensures staff achieve performance goals and adherence to company policies.
3. Ensures that the UM team is properly trained to conduct medical necessity reviews on incoming pre-service/prior authorization, on routine and expedited referrals requests in compliance with Federal, State, Health Plan and NCQA standards.
4. Ensures UM team documents on the medical management system timely, all supporting clinical information, outreach attempts and criteria used to make a determination.
5. Monitors, tracks, and reports any inappropriate referral patterns to the UM Medical Director and Director of Clinical Services
6. Serves as a subject matter expert on appropriate use, interpretation and documentation of clinical criteria in the review process using NCD, LCD, Health Plan Medical Guidelines, MCG, NCCN, etc.
7. Facilitates an atmosphere of interactive management and the development of collegial relationships among personnel and others, serving as a link between clinical and the healthcare disciplines
8. Collaboration with clinical personnel and members of other disciplines, participates in an organizational policy and procedure formulation and decision making, accepts organizational accountability for services provided, and evaluates the quality and appropriateness of care.
EDUCATION/EXPERIENCE:
- Bachelor’s degree in a health care related field
- At least 2 years of management experience in a Medical Group, MSO, Hospital, or Health Plan setting
- At least 5 years of experience in UM/Managed Care setting
LICENSURE/CERTIFICATE/TRAINING:
- Registered Nurse (RN) in the State of California, additional licenses in State of Texas and Arizona will be a plus
